Ebola makes the definitive case for health workers and strong health systems

This blog was originally published by Global Health TV on Nov. 25, 2014.

Since I first wrote about Ebola here at Global Health TV two months ago, the number of Ebola deaths has more than doubled, to 5,459, and the number infected has reached 15,351, according to the World Health Organization. Ebola has caused countless angst and affliction, mostly in West Africa but also in Spain and the U.S.

But there is one good thing that Ebola has done: It has made the case for strengthening health systems and frontline health workers more effectively than we in global health have been able to do. It has shown that weaknesses in health systems in poorer countries can affect people in richer countries. It has made that case not only to the global health community, but to the entire world.

“Weaknesses in West Africa’s health systems do not affect just West Africa – they affect us all,” said Pape Gaye, president and CEO of IntraHealth International, in testimony to the U.S. Senate Appropriations Committee on Nov. 12. “Ebola, HIV and other viruses and infectious diseases do not respect borders. Globally, our countries’ health systems are interconnected, creating one global interdependent health system. Today, that system is woefully precarious.”

Years of investments put health workers on global stage

Two midwives in a low-income area of Jakarta, Indonesia that are part
of DKT's "Andalan" social franchising network.

This article was originally published in The Huffington Post on Sept. 23, 2013.

For almost 10 years, I managed health programs in Africa, Asia, and South America that harnessed social marketing techniques to produce tangible benefits for poor consumers. Our programs made low-cost products such as condoms, contraceptives, and oral rehydration salts available at reduced, affordable prices. We worked mostly through the private sector and were proud of our bottom-line health impact. We didn't think much about underlying health systems or how to improve them. And if we had, we probably would have dismissed health system strengthening as overly ambitious.

But I've been thinking more about health systems lately, as I have seen governments and their nongovernmental partners carefully and patiently nurse ailing systems to health. The payoffs are not immediate -- far from it -- but as we move away from the segmented solutions to global health that prevailed in the 2000s (such as in the cases of AIDS and malaria) and toward greater country ownership, there is a growing consensus that we need stronger health systems to make sustainable improvements in global health.

This means more, better trained, and better managed frontline health workers -- the backbone of health systems.

I've heard that mantra for the last few years but, in 2012 and 2013, I saw it play out repeatedly as I traveled to very different countries in Africa, Asia, and Latin America:

Quacks, traditional healers and village doctors: Informal providers emerge as force in health care

An advertisement for a traditional healer in Zambia.

This piece was originally published on the PSI Impact Blog on April 9, 2013.
 
In my nine years managing social marketing programs for PSI in Africa, Asia and Latin America, I had two significant encounters with the category of health workers now known as “informal providers,” in Zambia and Bangladesh. In both cases, my PSI staffs and I decided to try to work with them because it seemed like folly not to work with them, given their numbers and their influence.

In Zambia, where I founded and managed PSI’s social marketing program, I became aware of the large and prominent role of traditional healers in the health system. They were everywhere – including where there were few or no formal providers – and were a respected part of the health landscape. Eventually, I became convinced that we should engage them in our HIV prevention condom social marketing program.

Realizing that traditional healers, like most players in the private sector, are motivated by financial gain, we recruited them as condom vendors, just as we had recruited wholesalers and retailers like pharmacies and grocery stores. Traditional healers saw condoms as a business opportunity and started out as good sales agents. Unfortunately, they were not always trustworthy business people: They insisted on buying on credit, but would not settle their accounts after making sales, so we had to terminate our relationship with them. Nonetheless, it was my first lesson in the importance of trying to engage traditional healers and other types of “informal providers” outside the formal health system, challenging though they could be.

Earlier this year, I started learning more about informal providers from the Center for Health Market Innovations (CHMI) which has supported studies of informal providers and focused a lot of attention on their contributions to health systems around the world.

In South Africa, an HIV campaign with a personal touch struggles to show its relevance

A Banake field worker talks to a family in Khayelitsha. Photo by Nicole Safker.

NOTE: This was originally published on the Knowledge4Health Blog on March 5, 2013.

Residents of Khayelitsha worry about a neighbour’s daughter who is only 13 but does not go to school because she cannot afford transport. She was raped by an old man. Her mother does not care and drinks a lot, swears at her about the rape and hits her. The child wants to go to school, so she went to stay in a neighbour’s home. The neighbour is also struggling and cannot afford the transport and school fees. – Banake Initiative Field Worker Diary

This is only one of many heart-breaking stories from the notes of field workers involved in an effort to improve communication among families affected by HIV/AIDS and encourage them to use HIV prevention services in Khayelitsha, the largest township of Cape Town, South Africa. The notes reveal shocking callousness and indifference on the part of township residents, but also compassion, like the neighbor who gave shelter to the 13-year-old girl.

The Banake Initiative was started in 2009 by DKT South Africa, an affiliate of DKT International, whose normal approach is focused on getting affordable health products and services to low-income people through the private sector. However, DKT decided that a different approach was required in South Africa, where HIV prevalence of people 15-49 has been stuck at around 17% since 2003 (the fourth highest rate in the world) despite years of work by many well-financed programs and the excellent availability of condoms (In November 2012, UNAIDS announced that the rate of new infections in South Africa had been reduced by 41% between 2001 and 2011).

In Costa Rica, strengthening health systems has a human side

A lab technician at the blood bank of Hospital de los Niños in San Jose.

NOTE: This originally appeared on the Impatient Optimists blog on February 28, 2013.
 
SAN JOSÉ, Costa Rica — Until I came here, I thought of “health system strengthening” strictly in clinical, technical terms – as a set of procedures for improving HIV testing, disposal of bio-waste, and health data management.

It is indeed all of those things, as I learned during a visit to a program working to improve care for people living with HIV led by IntraHealth International , a non-profit organization that empowers health workers to serve better communities in need,  but it also has a more human side.

Over two days, I spoke with a dozen health workers and managers about IntraHealth’s Central America Capacity Project. Several of them referred to these technical improvements as the calidad (or quality) side of health system strengthening, but they seemed to place equal emphasis on calidez (warmth). Many of the calidez changes can be made without incurring much, if any, financial cost. Virtually all of the health workers I talked to gave me examples of calidad and calidez:

• A lab technician at Hospital Dr. Max Peralta in Cartago, about 20 kilometers from downtown San José, emphasized improved procedures in handling of bio-wastes (calidad).
• The head of the blood bank at the Hospital de los Niños (Children’s Hospital) said that one of Capacity’s most important changes was simply securing a room where blood bank staff could talk to blood donors in private (calidez).
• Dr. Luis Ledesma, former director of Hospital de las Mujeres (Women’s Hospital), says Capacity has improved both types of health care, and he gave an example of each. Calidad: Improving and increasing HIV testing. Calidez: Calling a person by their name.

G8 Talks the Talk, but Breaks Prior Promises

L’AQUILA, Italy — The G8 released its communiqué on health, water and sanitation commitments to Africa Wednesday and, as I predicted in an earlier blog, the NGO community here is not impressed. But neither are they surprised. The communique largely reaffirms previous promises, at which the G8 has become quite accomplished.

There are some things I like a lot, especially the G8’s pledge to ”accelerate progress” on combating child mortality and on maternal health, “including sexual and reproductive health care and services and voluntary family planning.” I think those areas of health have been long neglected but regret that the G8 countries did not establish a more formal mechanism from making those laudable goals reality.

I also like a reaffirmation of a $60 billion pledge to fight infectious diseases and strengthen health systems by 2012 and the establishment of a mechanism to monitor health commitments made at the last three summits, which may be the only significant new health commitment made here at L’Aquila.

What I don’t like, and this feeling is widespread among civil society representatives here, is the indisputable fact that the G8 has not come close to meeting past commitments. In fact, The DATA Report, the most credible source of information on this subject link text, says that the G8 had delivered only one-third of all assistance increases it had promised to deliver to Africa by the end of 2010. I write about this more in my last blog.

I must hasten to add, though, that the U.S. is one of the least guilty of the G8 members on this score. The DATA Report points out that the U.S. increased its assistance to Africa by 26% in 2008, a significant increase that outpaced the global average of 16%, and is now on track to meet or even exceed its 2010 target. It may surprise many that former President George W. Bush can take much credit for this development.

However, the NGOs represented at the G8, largely European, were not pleased with the communique’s language on global health, water and sanitation, climate change, education, and the economy as laid out in a letter to Italian Prime Minister Silvio Berlusconi and the other seven G8 leaders earlier this week.

“The communiqué is pretty disappointing with no real new initiatives or recognition of the dire state of the progress to meeting their previous commitments,” said Kel Currah, chair of the Global Call to Action Against Poverty G8 Working Group, which represents a broad cross-section of NGOs at the G8. “On the good side, they did produce an accountability annex but again, this was only for a few of their commitments and there are a lot of holes in the report.”